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All rapid responses

Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Melanie Newman asks whether Cochrane has ‘lost its way’ given recent ructions arising from the Governing Board’s decision to remove membership status from Peter Gøtzsche. On the contrary, by all objective measures, Cochrane is thriving.

Feel free to ignore the evidence of sustained income growth that Newman cites. Look instead at the continuing international spread of Cochrane’s networks, increasing its reach in South America, Eastern Europe and South East Asia, and initiating new networks in China and the United States. Look also at the expanding work on multi-language content development, and the doubling in access to review summaries on the Cochrane.org website over the last 12 months, dominated by people from non-anglophone countries. In terms of impact, the use of Cochrane Reviews in guidelines continues apace, most notably at WHO, where in recent years 75% of guidelines produced annually have included Cochrane Reviews. Cochrane is also seeing an expanding number of people getting involved in or supporting its work. In addition to the 12,500 Cochrane members Ms Newman recognises, there are now an additional 43,000 actively registered supporters (compared to 28,000 contributors in 2012).

Underlying this success are the international author teams and 52 Cochrane Review Groups (CRGs), yet they barely rate a mention in Ms Newman’s article, and only one Co-ordinating (lead) Editor is quoted. Likewise, there is no mention of the contribution of the methods community, whose members provide the guidance and methodological peer review that are a crucial part of Cochrane’s international standing.

Cochrane must not be complacent – there are challenges ahead and continued success is not guaranteed. There is undoubtedly concern within the community about the growth of the Central Executive Team (CET) and legitimate questions about the most effective way that Cochrane can invest its resources. It is important that these do not become destructive or divisive. Cochrane is at its most effective when it adheres to its 10 key principles, which promote a culture that is open, diverse, inclusive and outwards facing, a community that is vibrant and iconoclastic, and a mission to search for truth and realism in health care.

It is regrettable that Ms Newman’s article follows a trend that has been evident elsewhere by personalising the blame for Cochrane’s perceived challenges on one person, Cochrane’s CEO, Mark Wilson. This argument neglects Mark’s positive contributions; from the development of the Strategy to 2020, to expanding Cochrane’s international reach, to initiating a membership scheme to open up Cochrane to the world, to providing the infrastructure support for the production of more challenging reviews, and to his commitment to pursuing diverse knowledge translation activities. Rather than credit these positive contributions, the critics focus on the necessary, overdue introduction of 21st century measures relating to good governance and accountability.

Some errors are also unchallenged. Cochrane guidance does not ‘still allow reviewers to review their own studies’. In contrast, Cochrane’s guidance states that trialists should not assess or extract data from their own studies. It is true that Cochrane’s existing strong COI policy is in need of clarification and revision, and this work is in progress.

Whilst all of this goes on, the real Cochrane engine room, the vast and sometimes quiet majority that just wants to produce and disseminate high quality reviews, and to support others engaged in that endeavour, just carries on its work. As Jeremy Grimshaw has noted, despite the recent controversies, between October and December 2018 390 new and updated Cochrane systematic reviews were published, and 1223 Plain Language summaries were translated into 14 languages. In other words, life has continued.

Competing interests:
I am a full time salaried employee of Cochrane but the views in this article are my own. I have previously announced that I will be leaving the role as Editor in Chief at the end of May 2019. Between 2003 and 2009 I was a full time salaried employee at the BMJ.

There must be procedures for removing elected individuals from office if they have committed serious misconduct but the process must be fair. My concerns about the removal of Peter Gotzsche from the Board of Cochrane are that the procedure was not fair and the conduct of Gotzsche did not constitute serious misconduct. It appears that the removal of Gotzsche from Cochrane’s Board was engineered because he had acted in the way that those who voted for him expected he would act. So his expulsion was undemocratic. Misuse of an adjudication procedure is particularly troubling because Cochrane exists to provide impartial assessment of evidence.

There are ongoing concerns involving the conduct of the Cochrane’s Governing Board relating to Peter C Gøtzsche's expulsion from the Board as well as the governance of its branding and products purporting to support evidence-based medicine.

Melanie Newman has done an excellent analysis of the current issues with Cochrane's credibility as well as future direction.

Her article reminded me of the classic episode of Yes Minister The Compassionate Society (Ref 1) in which the Civil Service (and the Union) are more interested in keeping the 'overworked' administrative staff employed churning out memos when there are actually no patients in a fictional St Edward's Hospital.

Similarly the core business of Cochrane in production of systematic reviews has been relegated to becoming "a machine, churning out reviews," in part due to how Cochrane is assessed (by the UK's National Institute for Health Research responsible for its funding) based "on how many reviews it produced rather than their impact".

Tom Walley's assertion that “Cochrane should focus less on quantity and more on methodologically high quality reviews in areas of importance to patients" rings true for many clinicians, particularly those who feel that the nature of the review does not address their (and their patients') practical concerns, hence the alienation and disengagement of these key stakeholders in healthcare.

No doubt many of the recent systematic reviews are performed to essential core standards but the delivery of the messages regarding the findings could have been far more engaging and practical at the grassroots level than it has been so far.

This, coupled by the 'ivory towers' perception of Cochrane by various healthcare providers at the coalface, has already weaken its credibility; the civil war involving governance, corporatisation and conflicts of interest in the manner involving industry interaction now suggest the spirit of 'Collaboration' is now replaced by disillusionment, disenchantment and discontentment amongst its key supporters.

Trish Greenhalgh may not think there is "a crisis of either morality or democracy" but suggests "it gets its house in order" (ref 2); she does not appear to have openly changed her stance since her blog in Sept 2018.

I, on the other hand, think Cochrane's branding had taken a serious blow (and one which may prove to be fatal if the current direction its Board has taken is not corrected).

Certainly, Cochrane will need to sort itself out through a rebirth to its core before it can seek to lead again in the pursuit of Evidence Based Medicine.

The print version is missing a paragraph ( see below) from the ‘corporation ‘ section. It makes less sense without this para, because the first mention of ‘ grimshaw’ is in the ‘ where next’.
There’re is no need to make this more confusing than it already is !!

Jeremy Grimshaw, who was co-chair of the Cochrane board from 2010 to 2014 recalls opposition to increased central spending. “There were people who argued that we should be splitting the money between the review groups fractionally, according to their contribution,” he says. “If we’d have done that each group would have gained a small amount that would not have helped their own sustainability and left Cochrane’s central team at risk.”

I am worried reading the title. I pray that it is not true. If only the Cochrane collaborators think and understand how valuable an unbiased data review can be especially in countries where economies are constrained and people believe in best evidence available to make treatment decisions which might help prolong lives or otherwise!

The detailed and sequential happenings at Cochrane make sad reading, particularly when the title reflects a serious deviation from / loss of the way itself. Individuals can be accused of being strongheaded with thinking that can be unidirectional; being accommodating and understanding of a different viewpoint does not necessarily always mean a yielding compromise. In most large organisations, vested interests invariably tend to develop; however, with checks and balances, it is possible to ensure that the basic structure and objectives are retained with some changes that are inevitable with the passage of time and changing situations. With the advances and strides in Medicine, there is an enhanced need for unbiased reviews to guide the physician in a situation with multiple therapeutic / interventional options available. The sight of warring factions does not augur well, but a solution need not remain elusive for long as that may be detrimental to the science of Medicine and its practice.

I'm struck by the sentence in the article stating "The more radical fringes of Cochrane campaigned for access to raw trial data and clinical study reports, looking for evidence beyond industry funded trials and analysis."

Is it "radical" and "fringe" to want access to raw data and to clinical study reports when we know how often negative data are left unpublished and when we know that positive outcomes often evaporate when unpublished data are included?

I've been worried about the direction of Cochrane long before the current brouhaha with Peter Gotzsche since some reviews have clearly been tainted by conflicts of interest (as I wrote in: Why we can't trust clinical guidelines http://bit.ly/2MHBCA8 )

And although I am a journalist, I cannot understand for the life of me, why a journalist was appointed to head Cochrane. It has the smell of commercial rather than scientific interest - an odor the leadership has done little to dispel.